Overview
Definition:
Compartment syndrome in children is a surgical emergency characterized by increased pressure within a fascial compartment, leading to compromised blood flow and potential tissue damage
It can affect any part of the body, most commonly the limbs.
Epidemiology:
While less common than in adults, pediatric compartment syndrome can occur following trauma (fractures, crush injuries, contusions), burns, prolonged immobilization, or iatrogenic causes (e.g., tight dressings or casts)
Age is a factor
infants and young children may present with subtle signs due to communication difficulties.
Clinical Significance:
Delayed diagnosis and treatment can lead to irreversible muscle and nerve damage, resulting in Volkmann's ischemic contracture, chronic pain, loss of function, and amputation
Prompt recognition and intervention are crucial for limb salvage and optimal functional outcome.
Clinical Presentation
Symptoms:
Severe pain disproportionate to the injury
Pain with passive stretch of the muscles within the affected compartment
Numbness or tingling (paresthesia) distal to the compartment
Weakness or paralysis of muscles within the compartment
Decreased or absent distal pulses (late sign)
Pallor or cyanosis of the distal extremity (late sign).
Signs:
The classic 5 Ps: Pain, Pallor, Paresthesia, Paralysis, Pulselessness
However, the 5 Ps are often late indicators, especially in young children
Pay attention to signs of distress, irritability, and reluctance to move the limb
Tense, woody feel of the compartment on palpation
Ecchymosis or swelling may be present but are not specific
Vital signs may be normal initially, but can show signs of shock if hypovolemia is present.
Diagnostic Criteria:
There are no absolute diagnostic criteria
diagnosis is primarily clinical, supported by compartment pressure measurements
Suspect compartment syndrome in any child with a traumatic limb injury experiencing disproportionate pain, especially with passive stretch
The decision to proceed with fasciotomy is often based on clinical suspicion when pressures are elevated or borderline, and there is a high index of suspicion for ischemia.
Diagnostic Approach
History Taking:
Detailed history of the injury mechanism (blunt trauma, crush injury, fracture, burn, prolonged immobility)
History of any preceding medical conditions or medications
Assessment of pain severity, location, and aggravating/relieving factors
Inquiry about any sensory or motor deficits
Previous similar episodes.
Physical Examination:
Systematic assessment of the affected limb, starting distally
Assess for sensation (light touch, pinprick), motor function (active and passive range of motion), and perfusion (capillary refill, color, temperature, distal pulses)
Carefully palpate the compartments for tenseness and tenderness
Crucially, perform passive stretch of the involved muscles, noting if it elicits severe pain
Assess for any limitations in movement due to pain.
Investigations:
Compartment pressure monitoring is the gold standard
A handheld manometer or a specialized transducer system can be used
Pressures >30 mmHg in adults, or >20 mmHg with diastolic pressure <30 mmHg, are generally considered diagnostic
In children, thresholds may be slightly lower, with >30 mmHg being concerning
Serial measurements are vital
Ultrasound may show swelling within the fascia
X-rays are used to identify associated fractures but do not diagnose compartment syndrome
Laboratory tests like CBC, electrolytes, and renal function are important for overall assessment and to rule out other causes of pain or swelling.
Differential Diagnosis:
Fracture with soft tissue injury
Deep vein thrombosis
Cellulitis
Peripheral nerve injury
Vascular injury without compartment syndrome
Crush syndrome
Pain syndromes such as reflex sympathetic dystrophy
Gas gangrene (rare).
Management
Initial Management:
Immediate cessation of any constricting factors (e.g., tight dressings, casts)
Elevation of the affected limb to the level of the heart to improve venous return
Pain control with analgesics
Sedation may be required if the child is uncooperative with examination or pressure monitoring
Avoidance of limb dependency
Prompt consultation with pediatric orthopedic surgery.
Medical Management:
Pain management is paramount
parenteral opioids are often necessary
Adequate hydration is important
Avoidance of fasciotomy without clear indication can be guided by strict serial pressure monitoring
Antibiotics are indicated if there is an open fracture or suspicion of infection.
Surgical Management:
Fasciotomy is indicated when compartment pressures are unequivocally elevated (typically >30 mmHg, or delta pressure <30 mmHg) and there is clinical suspicion of ischemia, or if pressures cannot be reliably monitored in a critically ill child
The procedure involves incising the skin and the overlying fascia to decompress the muscle compartments
Standard fasciotomy incisions for the lower leg involve medial and lateral approaches
For the forearm, volar and dorsal approaches may be used
The goal is complete release of all tense compartments
The fasciotomy wounds are typically left open and managed with delayed closure or skin grafting.
Supportive Care:
Continuous monitoring of vital signs, neurological status, and perfusion of the affected limb
Regular wound care to prevent infection and desiccation
Nutritional support as needed
Physiotherapy and occupational therapy are initiated once compartment pressures normalize and tissues are viable, focusing on regaining range of motion and strength.
Complications
Early Complications:
Nerve injury (e.g., peroneal nerve)
Muscle necrosis
Infection of the fasciotomy wound
Further swelling and ischemia
Compartment syndrome in adjacent compartments.
Late Complications:
Volkmann's ischemic contracture
Chronic pain
Loss of muscle function and strength
Limb length discrepancy
Deformities
Amputation
Post-traumatic arthritis.
Prevention Strategies:
Vigilant monitoring of patients at risk
Avoiding overly tight casts or dressings
Prompt recognition and treatment of fractures and soft tissue injuries
Early surgical decompression when indicated
Educating parents and caregivers about signs and symptoms.
Prognosis
Factors Affecting Prognosis:
The most critical factor is the time to diagnosis and treatment
The duration of ischemia before fasciotomy significantly impacts the extent of irreversible damage
Age of the child, mechanism of injury, and the specific compartment involved also play a role.
Outcomes:
With prompt diagnosis and fasciotomy (within 6-12 hours of onset), functional outcomes can be excellent, with minimal long-term sequelae
Delayed treatment leads to higher rates of permanent nerve and muscle damage, contractures, chronic pain, and functional deficits, potentially requiring multiple reconstructive surgeries or leading to amputation.
Follow Up:
Long-term follow-up is essential, typically involving regular orthopedic and physiotherapy assessments
This focuses on monitoring for the development of contractures, assessing muscle strength and function, managing chronic pain, and addressing any psychological impact on the child and family
Repeat imaging may be needed to assess bony union or soft tissue healing.
Key Points
Exam Focus:
Compartment syndrome is a surgical emergency characterized by increased intracompartmental pressure leading to ischemia
It can occur in children following trauma
Key clinical signs include pain disproportionate to injury, pain with passive stretch, paresthesia, and paralysis
Pulselessness is a late sign
Compartment pressure monitoring is crucial for diagnosis
Fasciotomy is the definitive treatment
Delayed treatment leads to irreversible damage and contractures.
Clinical Pearls:
In young children, irritability and refusal to move an extremity are red flags for compartment syndrome
Always check for pain with passive stretch of all muscle groups in an injured limb
Do not rely solely on distal pulses
measure compartment pressures if suspicion is high
Consider fasciotomy even with borderline pressures if clinical suspicion is strong, especially in a child who cannot communicate effectively.
Common Mistakes:
Delaying fasciotomy due to over-reliance on distal pulses or absence of overt swelling
Failing to monitor compartment pressures serially
Not considering compartment syndrome in the absence of a clear fracture
Inadequate decompression during fasciotomy, leaving some compartments still tense
Overly aggressive cast or dressing application
Not suspecting compartment syndrome in the infant population due to vague symptoms.